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032-2132-30-000
f - Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM COU Safety and Buildings Divisiont. CiroiX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanit3X 965No.. Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)). Permit Holder's Name: ❑City ❑ illa e o of: State Plan ID No.: Nelson, Ken or�ersetlownshi CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: L (S M) , '0 C%D . 3 i _ S � � A 1 032- 2132 -30 -000 TANK INFORMATION ELEVATION DATA 0 " 3O ' t � ` f" 12- TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark S; 75- DS: • a r Dosing Alt. BM - Aeration Bldg. Sewer Co-3 914Y l Holding St / Ht Inlet .60 x• - TANK SETBACK INFORMATION St/ Ht Outlet , o g6-I,$ TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet �^ Air Intake Septic SOt $. 5O NA Dt Bottom Dosing �z - NA Header /Man. Aeration NA Dist. Pipe 2 9 6 r Holdin Bot. System - '' `j4 •Zo PUMP/ SIPHON INFORMATION Final Grade �S S. . fo.o I vi. 15 - Manu cturer and Model Nuhkber G TDH L' Friction System TDH Ft 0rcemain Length Ff oist.T I SOIL ABSORPTION SYSTEM 2 ` BED/TRENCH Wi jh Len tl? N9. f Trenches DIMENS No. Of Pits Inside Dia. Liquid Depth DIM ENSION S Manu ctu er. SETBACK SYSTEM TO P/ L BLDG WELL, _ LAKE / STREAM LEACHING INFORMATION Type O r 'c� O UN T CHAMBE - Mod el N u r m er: System: tt ` ` TI DISTRIBU N SYSTEM Header / IBU off✓ 4 Distri tion Pipes x Hole Size �xHoes pa cing Vent To Ai; Intake Lengtty Dia. c Length Dia. 3 3 + SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes Q No ❑ Yes ❑ No M E TS: ( a ode discre ncle , ersons present, etc.) 06 1 2 F p/ C ) . sk �e a te� -.,.. . on: 872 174th Avenue, New Richmond, WI 54017 (NW 1/4 SE 1/41 T30N R19W)019 23 Rocky Ridge Estates -Lot 4 �� 1.) Alt BM Description =154 2.) Bldg sewer length= z [.o' - amount of cover =C L" N ` - 4� . Plan revision required? []Yes No 4 o� o I SZ(, U TD -6710 qt (R 97�� h= s' a for additio information. h�jR taD � ` Date Inspector's Signature Cert . No. .3/ I Z1 A 1 „52 0 o O IL ry 7 3.3.f — �� Z --q FOE Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 `� sconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce p (Submit completed form to county if not [Privacy Law, s. 15.04(1)(m)] state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. - 7 Couyty� C State Sanitary �P Permit ❑Check if revision to previous application State Plan I. D. Number �/� 1 I. Application Information - Please Print all Information Location: Property Owner Name Property Location / , 1 J / am✓ �. , - ,1 �, V&4 1/4 6E: /4, S T ,N, Rl (o Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number j-,— tc,� � :5 C / �. � ( 7 WY A II. Type of Building: (check one) ❑ City Id 1 or 2 Family Dwelling -No. of Bedrooms : ❑ Village ❑Public /Commercial (describe use):_ Q� Town of ❑ State-Owned t Nearest Road � r Parcel, fnber(s� J III. Type of ermit: (Check only one box on line A. Check box on line B if applicable) (' 3 2, — — 3 O — O D O A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to 3 System System Tank Only a, Existing System B) Permit Number Date Issued — ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ANon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade -- ❑ Aejobic Treatment Unit ❑ ecirculating ❑ Other: A - 0 C', �C�- -� I V. Dispers 1/Treatment Area Information: — — �_ 2 3 K �� TZ 1. Design Flo (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed ( s./da sq. ft.) (Min. /inch) Elevation f 3 e/D 5 y - VII. Tank Capacity in Total # of anufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass ew Existing crete structed Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statgment I, the undersigned, assume responsibility for installation of the POWTS sho n the attached plans. Plumber's Name (print) Plumb s Signature (no stam s): /MPRS No. Business Phone Number Plumber's Address (Street, City, State, Zip Code) IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Si nature (No stamps) 1>;( Approved ❑ Owner Given Initial Adverse Sur arge Fee) dD Determination 22S 21 21jo ' X. Conditions of Approval /Rea ons for � 4-0- s�ppr va : r -e s � s ��' n n n SBD -6398 (R. 07/00) C F iAl 3j 3� X 0 i3 X 3 X a l ei i fi Ty D M- 10L 103 a �� 15— Wisconsin Department of Commerce SOIL TE EVALUATION 3 Division of Safety and Buildings �� Page of Bureau of Integrated Services in actor ,nee?' Wifh:'s, ILHF�V.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 xI1 J irt 6hes in s�� ��)Pq..rAust \ County / r include, but not limited to: vertical and horizontal refer4rtc� point (BM), dif 4, nd percent slope, scale or dimensions, north arrow, and location and0st�nce to nearest meld j Parcel I.D. # + fJ3Z -� tiT t( St's�,, APPLICANT INFORMATION - Please prinf,all inform�� k ' Reviewe by Date Personal information you provide may be used for secondary pure ses(PnVWWi (1) Prop Owner P t% � pet3yt'- ocation Aa 55c'// 2 9, elf o,,? ��,�� '_.! � �o�YLot lybv 1/4,5,C1/4,S � T30,N,R /9 or) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# l7 / eY 5� AI 4 i Ri d g e .SA City State Zip Code Phone Number Nearest Road yeW 1�f'c�, 101 ❑ C El Village Q Town SVW 7 (7 /S j 2 V6 - 537 5 f 8S � `St New Construction Use: ® Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 4 � LI2 � 0JJ ' �� gpd Recommended design loading rate � bed, gpd /ft� a trench, gpd /ft Absorption area required " bed, ft 12 t 1 rench, ft2 Maximum design loading rate ' 09 ,-- bed, gpd /fP trench, gpd /ft Recommended infiltration surface elevation(s) • ft (as referred to site plan benchmark) Additional design /site considerations Parent material 6 I T '1 CA II Pc'. Z7 I D Atsr Jc 4.Oa/h Flood plain elevation, if applicable 1 41 1 A ft S = Suitable for system Conventional Mound In- Ground Pressure AT Grade System in Fill Holding Tank U = Unsuitable for system ®S Ely ©S ❑ U ®S ❑ U ©S Flu ❑ S ® U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench f 1 -17 10 2 in 730 /0f8 f� Si [. �'Sbk m „re C w j in .� 3 -7- Ground 3o- 7 5 Yk y (//� SG / m sbk i�v�'� — J� P . y Depth to limiting �f0.Qr jj in. Remarks: Boring # 8 A /9/1 3-Z 14 )m i ma-A, C 6v 2 M ) br/ IV WS'bK 07 S- 17 7SYiQ /y '” /M5At h1ufi Ground Depth to c� limiting ZED r in. Remarks: CST Name (Please Print) ignature Telephone No. r 16 A V Z y7-3Z �3 Address yd // 2 �, e �I h ej t (/" }� �i z S Dat m er �7 r PROPERTY OWNER � ` GC SSe�� U �efP�r � SOIL DESCRIPTION R PORT k ' Page � of 3 � PARCEL I.D.# 0,72- Z006 -/0 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench IYA S msbk m1) F 7 - 3 /�Ylf F-26 /�' A,f'f G w � ►� .:z ;. 3 Z Ground 3 18 Z-Ftl' %y /�/ ` jhfsbk riiu�'r — ��,� ,V f d it. Depth to limiting �in. Remarks: Boring # �� QY/� S� /i'►Sbk h?vfr Gw 2 t' L /w-s k m vr P AIA SL /Asb� AV -1c — r .-V Ground :A Depth to �� 2 limiting (. >� in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Mu Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # 7 M S 2 - /0 6 1� Sbk m0 . C w th .2 ; , Z 3 9- 7 s YX %y Ground I7 l ft. Depth to q3 2 limiting A r— in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) , I Jl iel� �ch'int u.� WTI! - i 1 4 - - -- r -. - � hCb _2 _ 72 - AhC�� (i�6S i Yo!C.C.1"' 2C2J�- . tco nnp,- i I + , I i : , I t 1 f _ r {{ s ! ' I I �© i , I I , , M , , t S . } ♦ }{r o, irr 'a .rr. ♦ ✓ {'•FtT• %•••fi ,°ti, }1 /�►� � Po •,� ' - r; ( ',1lifNN fF�. • ° ^ }; °' .j:�� •: • Ire ;:.• • ': }'{•. •• /y AMEN 1p ♦, Yr : :� l Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number Number of Bedrooms 3 r Design Flow - Peak (gpd) 1 -1 Estimated Flow - Average (gpd) 3 �O Septic Tank Capacity (gal) 0 Soil Absorption Component Size (ft _ j j FXT 2 Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) �n Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septi and outlet filter shall be assessed at least once every 3 years by inspection. The utlet filter shall be cleaned as necessary to ensu p mp.Q,=r operatinn The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 FROM : PC COLLOVA BLDR &BROTHERS EXC FAX NO. : 7152943245 Apr. 17 2001 07:02AM P4 ST CROIX COUN'I'Y SEPTIC TANK MAIN'I P -NANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM n n �► n ►► �,, / Owncrli3ttyer Mailing Address `TOE d . /- 7 Lu = S Property Address A Vcf� rif required from Planning Department for new construction) Alb. tZi r—fuD .� City /State J— ParceI Identification Number �, �— ?o(3 LEGAL DESCRIPTION Property Location 1 `t w %, %5 v, S T 30 N_RgW, Town of �p . Subdivision K Lot It �v® C-SAL Certified Survey Map ff Volume . Page It Warranty Decd # 0 Volume f Page a f�a Spec douse O yes �A Ito Lot lines identifiable yes Q no SYSTEM MARM NANCE Improper use and maintenaneeof your septie systcm could result in its prematurafallure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper, What you put into the systcm can attect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Dcparttncut a certification form, signed by the owner and by a tnasterplumber, journeyruanplumber, restrictedplumberora liccasedpumpervcayiug that(1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and ptemping (if necessary), the septic tank is less that( 113 full of sludge. Ilwe. the undersigned have iccad the above requircments and agrce to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, Stale of Wisconsin. Certi[ication stating that your septic system has been maintained must be completed slid returned to the, SFr Croix County Zoning Office within 30 Z dfj Cite three year expiration date. IGNATURE OF APPLICANT DATE O E CE- RTIr,ICATION I (we) Certify that all statements on this form are true to the best of n ► (our) kn owledge: I (we) a (are) tIrc ownci(s) of the mperty described above, by virtue of a warranty decd recorded in Register of Deeds Office. § 1 1 14AYLTRE OF APPLICANT DATE • "••• Any infotmatiou that is niis representedmay result in the sanitary permit being revoked by the Zoning Department. ••' ••• •• Include with (Ills application: a stamped warranty decd from the Register of Deeds office a cony of the certified survey map if reference is made in the warranty deed V1 .11.1561m 169 634043 STATE BAR OF WISCONSIN FORM 2 - 1999 KATHL_FFN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. rROIX Co. WI This Deed, made between Tim A. R and RECEIVED FOR RECORD Karl S koglun d 11 -24 -2000 9:30 AM WARRANTY DEED - - --._ -_, EXEMPT Y Grantor, and Ken neth E. Nelson a nd Beth M. Ne husband and CERT COPY FEE: _ - - — COPY OFF.: wife, TRANSFER FEE: 170.70 _ __ - --_ -- — RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croi County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot 4, at of Rocky Ridge Estates in the Town of Somerset, St. Croix Name and Return Address nty, Wisconsin. KRISTINA OGLAND ATTORNEY AT LAW P.O. BOX 359 HUDSON, WI 54018 03a -aoo -/ y Parcel Identification Number (PIN) This is not _ homestead property. 04) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this Se day of 2 000 y * Timothy A. Riemensch * Karl Sk an AUTHENTICATION ACKNOWLEDGMENT Signature(s) Timo A. Ri a Karl S koglund STATE OF WISCONSIN ) ) ss. �n County ) authenticated this 2U day of _ Uk �t/e°ii,.�( - Personally came before me this _- day of the above named Kristina O gland -- " - TITLE: MEMBER STATE BAR OF WISCONSIN — - - - - -- - - (If not, to me known to be the person(s) who executed the foregoing authorized d b y § 706.06, Wis. Stats.) - -- — - instrument and acknowledged the same. b THIS INSTRUMENT WAS DRAFTED BY • _ _ _ _ Attorney ri stina O land — y $ ._ Notary Public, State of Wisconsin Hudson, W 54016 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) _ _ I.. _ -_... .) ' Names of persons signing in any capacity must be typed or printed below their signature. irrormaton Proressionsis company. Fora du tac, W STATE BAR OF WISCONSIN 800-655 -2021 WARRANTY DEED FORM No. 2 - 1999 . r. ROCKY FUDGE ESTATES oucrae a th. sauln.wt t>rurt. as nu seua.ea oucrer a fh [ouc,eeef tAwrbr a a SeNo, f. rer.nfn 70 Rrtc,, ff.ce fc wa, r..,, a amwwf, cf, aaf. o..b, M.mi+: y=q iwr[, a fM frlroi.n c.ara ero fermi m[°MA ■ � c sfws �--� - _.�_ � r JUL • Loris car � e -...__ D I I� nxmn. s RECE JA ICA![ / .a ,[ r 13j am ,[ 1 44-M m p y I,�saasr I� 1 mm AN dC•J \ CaUN c77111nGor. ICff ^�±'> ? M1 :Anmu � 9 0 1 Iskm r �^ CURE DATA TAKE dbL Y R cor„ I mo• tsa[f - ..� ! R 3 f /Aavf M = W —. � a . •r*,+M • - N' M e.a y � �i :J I.:. I... " '' .r", .�..+ "..T.."'a+,`,.'7, .`�.�. rte., �. B i b _ • -� - *,� "W It wr,l s u �o� m n. o r...... r.. fcla,a use a[[ fr.w m nc rt. am moor c r r r sA[.fafeJ ffm r.. x.. wp -r_,�f Iu ucw raa.o[xn xK fn, ra m fr[ rum x l,) �• r • � � r • . w. •melt eeweopre [o[ rue >0 �.ewr.. •r+w [...u., M,+„+.) 'm emm me mmo ert m.mm m=e vem .aK . }.. _.. _.._. � + _.. _. _..- .._.._.._......_.. ._.. -.. co aemxe m conwcme rtnm M rrn rtmrmnc ;''+.,�..- ... -. ^1 / JAI 'pow